Provider Demographics
NPI:1669688644
Name:KELLEY, DAVID G (DMIN)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 COURTNEY DRIVE
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901
Mailing Address - Country:US
Mailing Address - Phone:239-278-3231
Mailing Address - Fax:239-278-4227
Practice Address - Street 1:1950 COURTNEY DR
Practice Address - Street 2:SUITE # 2
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9034
Practice Address - Country:US
Practice Address - Phone:239-278-3231
Practice Address - Fax:239-278-4227
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0000494106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist